The related factors of compliance to professional codes of ethics from midwives' perspective working in healthcare centers of Tehran-Iran

Introduction Professional ethics is an important issue in every organization. This study was designed to define compliance level to professional codes of ethics and some of its related factors in midwives working at healthcare centers. Methods This cross sectional study was conducted in 2013 Tehran Iran. 125 midwives from the governmental healthcare centers of Tehran were selected through stratified quota sampling method. Data gathering tool was a self-reporting questionnaire which included: demographic characteristics, Iranian version of ethical codes of reproductive health providers, applicability of these ethical codes and awareness about the professional codes of ethical. Data analysis was conducted using SPSS v.16. p level at 0.05. Results Compliance to the professional ethical codes were directly correlated to the income level of the midwives, the applicability of the codes and the midwives' awareness about them. Conclusion It is necessary to pay attention to professional ethics and its teaching as such. It is also important to monitor compliance to the ethical codes. Moreover, living conditions of the midwives should be one of the priorities to enhance their performance.


Introduction
Medical ethics is an interdisciplinary subject and its content is moral values of medicine. Therefore, the necessity of compliance to the moral values and the uniformity in care and the treatment behavior are of critical importance [1]. Experts in medical ethics emphasize on the widespread use of ethical codes in the field of health care [2][3][4]. Ethical performance is one of the main factors in providing quality care to women and mothers. It is necessary for the health care personnel, at any position of service, to base their performance on common values which are indicators of their loyalty to the society and their profession as well [5]. All over the world, midwives satisfaction is one of the main requirements for maintaining and improving reproductive health [6,7]. Midwives are responsible for the safety of women and supporting their empowerment. Therefore, they would encounter many important ethical issues during their professional activities [8,9]. Paying attention to all ages is one of the characteristics of the ethical codes of the health care providers [10]. Compliance to the principles and the ethical codes of midwifery would result in providing fair treatment/care, protecting patients/clients from unnecessary risks, enhancing recovery, improving and increasing patient's pain tolerance level, reducing patient's anxiety, making motivation for the patient to have a better cooperation with the medical team, reducing treatment costs, increasing satisfaction and strengthening mutual trust between the therapist and the patient [11]. It has been continuously suggested in recent years to consider medical ethics at three levels: 1) educating the professional ethics to the students, 2) compliance to the ethics during care or treatment and 3) managerial and executive level for the public health [12]. The experts of every profession should evaluate the level of compliance to the professional codes of ethics in their profession. In other words, to improve the performance of the system, experts need to study the ethical codes, assess the level of compliance and investigate factors that would affect them [13]. Reviewing relevant scientific sources revealed that there were not enough studies on how to check compliance to the ethical codes in providing midwifery care and treatment in Iran. Therefore, to assess the ethical performance of midwives, this study was designed to evaluate the compliance to the codes of ethics and its related factors among midwives in Tehran's governmental HCCs.
It is hoped that by knowing the performance of the midwives regarding the compliance to the ethical codes and also by knowing the factors affecting this compliance, which is a fundamental pillar of the health care system, a step, as small as it may, would be taken towards more effective programming for the compliance to the ethical principle.

Methods
This is a cross-sectional study that was conducted in Tehran-Iran in 2013. The sample size was calculated to be 125 midwives. The inclusion criteria were: having midwifery and having at least six months of work experience in the field of midwifery. The exclusion criteria were participant´s willingness to withdraw from the study (in fact, nobody withdrew from the study  Table 2. The applicability of each 10 domains are shown in Table 2. In this study, the mean of the awareness about the ethical points in midwifery was 4.6 ± 1.67. The rest of the specifications are listed in Table 3. Using Spearman and pearson correlation coefficient, it was identified that the compliance to the HCP ethical codes has a significant association with the midwives' income (p = 0.004). This was defined in a way that the more desirable income from the participants' point of view, the more compliance they showed to the HCP ethical codes. It was also identified that the compliance to the HCP ethical codes had a significant association with the applicability of these codes and with the awareness of the ethical points in midwifery as well (p=0.001) ( Table 3).

Discussion
This study was designed to assess the level of compliance to the  [15]. Baghani et al also stated that the level of compliance to the ethical principles in the field of professional midwifery responsibility and midwifery relationship were 50% and 86%, respectively. In addition, compliance was higher among the 7 th semester students compared to the 5 th semester students [16].
In Bazrafkan's study, compliance to the ethical codes by medical staff was at an appropriate level of 63% [1], which is in line with the results of the present research. Khodakarami [20].
Additionally, several studies showed the importance of truthfulness.
In most cases, enough information about the cost and the insurance services is not given to the patients [21]. In this study, the mean level of compliance to the right of maintaining client's confidential and from the patients' view "physicians" sense of responsibility" had the highest score [27]. As well, in the present study, the high scores obtained from the midwives may not be the same in the patients' opinion. In the current study, the mean of compliance to the professional relationship with colleagues by the midwives was 80.83 ± 6.67, which is at a good level of compliance. Appropriate and effective relationship between members of the medical team leads to a better compliance to the principles of professional ethics and results in higher patients' satisfaction. It seems that professional stress in the workplace (hospitals and the HCCs) had an important effect on the satisfaction with the colleagues. Psaila et al showed that the success of the health care system is directly related to good behavior and correct interactions between the professionals working together [28].
In this paper, it was tried to work on some factors related to the compliance to the HCP ethical codes from the perspective of the

Competing interests
The authors declare no competing interests.

Authors' contributions
Leila Nasiriani did conception and design, acquisition of the data and